Healthcare Provider Details

I. General information

NPI: 1104590165
Provider Name (Legal Business Name): CORINNE RUTH ESPINOZA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1125
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5592
  • Fax: 801-662-5985
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11881357-2501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number11881357-2501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number11881357-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: